1. Immobilization. During transportation, admission procedures, and
most of the early hospitalization period, immobilization of the
affected part and absolute rest should be continued. A sedative or
analgesic may be administered to relieve restlessness and anxiety; ice
bags may be applied to alleviate severe pain. The extremity should be
immobilized in the position of function, and active and passive
exercises to prevent contracture started after the third day if
consistent with the patient’s condition.
2. Blood Transfusion. Postmortem examinations have at times revealed
extensive retroperitonial and intraperitonial hemorrhage, and
hemorrhage into the viscera, including the liver and kidney.
Progressive decrease in the total volume of circulating red blood
cells has been attributed to the development of a massive hemolytic
anemia or internal hemorrhage. Blood transfusions may be necessary and
at times have been followed by marked improvement. Studies of the
several factors involved in blood clotting may be useful as guides to
treatment. The first and subsequent specimens of urine should be
especially examined for the presence of red blood cells, hemoglobin,
and protein.
3. Electrolyte Balance. Abnormality of fluid and electrolyte balance
should be detected and corrected on a continuing basis.
4. Antivenin. Polyvalent or specific antivenins prepared from venoms
of snakes in the same geographic area should be administered in
therapeutic quantity as recommended by the manufacturer only with full
realization that the hazard of immediate allergic reaction or delayed
serum sickness are factors to be evaluated in the decision to carry
out this type of treatment. During hospitalization, antivenin should
be given intravenously, provided that sensitivity tests indicate that
the patient is not allergic to the antiserum to be used.
Desensitization, if necessary, should precede the administration of
antivenin by any route. The use of antivenin in such cases should be
carefully evaluated. Injection in normal muscles in other extremities
would be the second choice, since local injections into the deposit
site do not diffuse efficiently into the entire damaged area and would
increase the hazard of pressure ischemia leading to increased tissue
necrosis. Epinephrine should be available for immediate use when
foreign protein is being administered.
5. Corticosteroids. The use of corticosteroids should be restricted to
the prevention or treatment of late manifestations of allergy
following administration of antivenins.
6. Antibiotics. A broad-spectrum antibiotic should be administered
promptly in appropriate dosage if the reaction to envenomation is
severe. Since the nature of the injury markedly predisposes to
infection, and pathogenic bacteria are found in the wound, this use of
antibiotics seems justified. Laboratory sensitivity tests, if
available, should control the continuing choice of antibiotics to be
used. A massive wound infection with severe systemic reaction could be
mistaken for severe envenomation. Repeated blood and wound cultures
would be of help in making the distinction.
7. Tetanus Prophylaxis. Tetanus toxoid should be administered upon
admission if it has not been given as a first aid measure.
8. Respiratory Paralysis. If respiratory paralysis develops following
envenomation by one of the _Elapidae_ (this family includes the coral
snake), the use of tracheostomy and intermittent positive pressure
artificial respiration is indicated.
9. Renal Shutdown has been an occasional occurrence following massive
envenomation. An awareness of this possible complication can do much
toward the prevention and treatment of secondary effects arising after
its occurrence. Routine daily tests such as B.U.N., CO₂ combining
power, and serum potassium levels are indicated in severe cases.